
<form name="editForm" role="form" novalidate ng-submit="vm.save()">

    <div class="modal-header">
        <button type="button" class="close" data-dismiss="modal" aria-hidden="true"
                ng-click="vm.clear()">&times;</button>
        <h4 class="modal-title" id="myIllnessInfoLabel" data-translate="byibserverApp.illnessInfo.home.createOrEditLabel">Create or edit a Illness Info</h4>
    </div>
    <div class="modal-body">
        <jhi-alert-error></jhi-alert-error>
        <div class="form-group" ng-show="vm.illnessInfo.id">
            <label for="id" data-translate="global.field.id">ID</label>
            <input type="text" class="form-control" id="id" name="id"
                    ng-model="vm.illnessInfo.id" readonly />
        </div>
        <div class="form-group">
            <label class="control-label" data-translate="byibserverApp.illnessInfo.illnessName" for="field_illnessName">Illness Name</label>
            <input type="text" class="form-control" name="illnessName" id="field_illnessName"
                    ng-model="vm.illnessInfo.illnessName"
                    />
        </div>
        <div class="form-group">
            <label class="control-label" data-translate="byibserverApp.illnessInfo.incidence" for="field_incidence">Incidence</label>
            <input type="text" class="form-control" name="incidence" id="field_incidence"
                    ng-model="vm.illnessInfo.incidence"
                    />
        </div>
        <div class="form-group">
            <label class="control-label" data-translate="byibserverApp.illnessInfo.diseaseDefinition" for="field_diseaseDefinition">Disease Definition</label>
                <textarea class="form-control" name="diseaseDefinition" id="field_diseaseDefinition"
                    ng-model="vm.illnessInfo.diseaseDefinition" ></textarea>
        </div>
        <div class="form-group">
            <label class="control-label" data-translate="byibserverApp.illnessInfo.susceptiblePopulation" for="field_susceptiblePopulation">Susceptible Population</label>
                <textarea class="form-control" name="susceptiblePopulation" id="field_susceptiblePopulation"
                    ng-model="vm.illnessInfo.susceptiblePopulation" ></textarea>
        </div>
        <div class="form-group">
            <label class="control-label" data-translate="byibserverApp.illnessInfo.medicalLevel" for="field_medicalLevel">Medical Level</label>
                <textarea class="form-control" name="medicalLevel" id="field_medicalLevel"
                    ng-model="vm.illnessInfo.medicalLevel" ></textarea>
        </div>
        <div class="form-group">
            <label class="control-label" data-translate="byibserverApp.illnessInfo.compensableCircumstances" for="field_compensableCircumstances">Compensable Circumstances</label>
                <textarea class="form-control" name="compensableCircumstances" id="field_compensableCircumstances"
                    ng-model="vm.illnessInfo.compensableCircumstances" ></textarea>
        </div>
        <div class="form-group">
            <label class="control-label" data-translate="byibserverApp.illnessInfo.unCompensableCircumstances" for="field_unCompensableCircumstances">Un Compensable Circumstances</label>
                <textarea class="form-control" name="unCompensableCircumstances" id="field_unCompensableCircumstances"
                    ng-model="vm.illnessInfo.unCompensableCircumstances" ></textarea>
        </div>

        <div class="form-group">
            <label data-translate="byibserverApp.illnessInfo.typeOfCase" for="field_typeOfCase">Type Of Case</label>
            <select class="form-control" id="field_typeOfCase" name="typeOfCase" ng-model="vm.illnessInfo.typeOfCaseId" ng-options="typeOfCase.id as typeOfCase.typeName for typeOfCase in vm.typeofcases"            >
                <option value=""></option>
            </select>
        </div>
        <div class="form-group">
            <label data-translate="byibserverApp.illnessInfo.product" for="field_product">Product</label>
            <select class="form-control" id="field_product" name="product" ng-model="vm.illnessInfo.productId" ng-options="product.id as product.id for product in vm.products"            >
                <option value=""></option>
            </select>
        </div>
    </div>
    <div class="modal-footer">
        <button type="button" class="btn btn-default" data-dismiss="modal" ng-click="vm.clear()">
            <span class="glyphicon glyphicon-ban-circle"></span>&nbsp;<span data-translate="entity.action.cancel">Cancel</span>
        </button>
        <button type="submit" ng-disabled="editForm.$invalid || vm.isSaving" class="btn btn-primary">
            <span class="glyphicon glyphicon-save"></span>&nbsp;<span data-translate="entity.action.save">Save</span>
        </button>
    </div>
</form>
